Endoscopic Treatment of an Idiopathic Pancreaticopleural Fistula

A 61-year-old man was diagnosed with an exudative pleural effusion with raised amylase and bilirubin levels. The patient had no previous history of acute pancreatitis or trauma and no clinical or radiological signs of chronic pancreatitis. On thoracoabdominal computed tomography, a pancreatic pseudocyst with a pancreaticopleural fistula was identified. Endoscopic retrograde cholangiopancreatography identified a ductal disruption site in the body of the pancreas. Pancreatic sphincterotomy and stent placement in the duct of Wirsung, combined with medical management, allowed fistula closure, pseudocyst reabsorption, and no relapse of the pleural effusion. The relevance of this case lies not only in its rarity but also as it highlights the importance of a multidisciplinary approach in such uncommon conditions. Optimal management of this condition is debatable due to the absence of prospective studies comparing medical, endoscopic, and surgical approaches.

Early Endoscopic Intervention in Pancreaticopleural Fistula: A Single-Center Experience

Background Pancreaticopleural fistulas are among the rarest complications of chronic pancreatitis. The main objective of the research, conducted on a total of seven patients, was to evaluate the effectiveness of early endoscopic management of pancreaticopleural fistula. Methods The diagnosis of fistula was reached when fistulous tract was demonstrated on imaging studies and/or pleural fluid amylase level was greater than 2,000 U/L. The data were retrospectively analyzed from the records. Results The prototype patient in our series was a chronic alcoholic male with median age of 45 years. Computed tomography scan was performed in all the seven patients but could diagnose leak only in four patients. Magnetic resonance cholangiopancreatography was better in the remaining three patients for diagnosing fistula. Endoscopic retrograde cholangiopancreatography was the most sensitive test that diagnosed fistula in all the seven patients. Pancreatic duct (PD) cannulation was successful and pancreatic sphincterotomy with PD stenting was performed in all the seven patients. We could avoid surgical intervention in our patients. Conclusions We advise early endoscopic treatment within 7 days of symptom onset as opposed to 3 weeks, which was proposed previously. Medical therapies should be complimentary to PD stenting.

Spontaneous Resolution of Hemorrhagic Pseudocyst-Associated Pseudoaneurysm in Groove Pancreatitis

Hemorrhagic pseudocyst (HP) and pseudocyst-associated pseudoaneurysms (PPs) are complications of pseudocyst. Angiography with embolization has been advocated as the first-line intervention for HP. A 47-year-old man with groove pancreatitis combined with HP near the pancreatic head was treated conservatively. He had relapsed pancreatitis with a newly identified pseudoaneurysm; however, the pseudocyst size was reduced. Although pseudoaneurysm was identified, angiography was not performed because there was no evidence of ongoing bleeding, and he was in a stable condition. Sphincterotomy and stent insertion in the pancreatic duct was applied to prevent relapsed pancreatitis with facilitation of the flow of pancreatic juice. He has done well during the 10-month follow-up, without recurrent pancreatitis. Angiography as an initial approach in HP and PPs may need to be more selective depending on the clinical presentation of the patient. A lysed clot within the strictured pancreatic duct during the healing process has been thought to be the cause of relapsed pancreatitis, and pancreatic sphincterotomy and stent insertion should be the preferred treatment methods.

Pancreatic sphincterotomy improves pain symptoms due to branch-duct intrapapillary mucinous neoplasia without worrisome features: a multicenter study

Introduction Branch duct intraductal papillary mucinous neoplasms (BD-IPMNs) require follow-up to detect worrisome features (WF). Data are missing about endoscopic pancreatic sphincterotomy (PS) for symptomatic IPMN. Patients and methods This was a retrospective multicenter study in four expert centers. Patients treated with endoscopic PS for symptomatic (painful) BD-IPMN without WF were included. Age, sex, follow-up time, characteristics of IPMNs and endoscopic retrograde cholangiopancreatographies (ERCPs), and indications for surgery were recorded. Results In total, 21 patients were included (median age 68 years, range 45 – 87 years). The median number of cysts was 2 (range 1 – 10), located in the head (59 %), body/tail (17 %), or multifocal (24 %). ERCP including PS was completed in all of the cases, with biliary sphincterotomy in 33 %. Clinical efficacy after one session was 81 % (17/21). Among the failures, one had a second successful PS and three were operated. The final efficacy was 86 % (18/21). Seven patients were operated after a mean of 19 months: four for WF, three for pain. The histopathology showed four low grade dysplasia, one high grade dysplasia, and two no dysplasia. No adenocarcinoma occurred during a follow-up of 99 months (range 14 – 276 months). Conclusions Endoscopic PS for symptomatic IPMN without WF is effective in more than 80 % of cases, without increasing the risk for adenocarcinoma.

10 Fr S-Type Plastic Pancreatic Stents in Chronic Pancreatitis Are Effective for the Treatment of Pancreatic Duct Strictures and Pancreatic Stones

Aim. Endoscopic pancreatic stenting for refractory pancreatic duct strictures associated with impacted pancreatic stones in chronic pancreatitis cases has yielded conflicting results. We retrospectively evaluated the efficacy of endoscopic treatment in chronic pancreatitis patients with pancreatic duct strictures. Methods. Pancreatic sphincterotomy, dilatation procedures, pancreatic brush cytology, and pancreatic juice cytology were routinely performed, and malignant diseases were excluded. After gradual dilatation, a 10 Fr plastic pancreatic stent was inserted. The stents were replaced every 3 months and removed after the strictures were dilated. Statistical analyses were performed to determine the risk of main pancreatic duct restenosis. Results. Endoscopic pancreatic stents were successfully placed in 41 of a total of 59 patients (69.5%). The median duration of pancreatic stenting was 276 days. Pain relief was obtained in 37 of 41 patients (90.2%). Seventeen patients (41.5%) had recurrence of main pancreatic duct stricture, and restenting was performed in 16 patients (average placement period 260 days). During the follow-up period, pancreatic cancer developed in three patients (5.1%). Multivariate analysis revealed that the presence of remnant stones after stenting treatment was significantly associated with a higher rate of main pancreatic duct restenosis (p=0.03). Conclusion. The use of 10 Fr S-type plastic pancreatic stents with routine exchange was effective for both short-term and long-term outcomes in chronic pancreatitis patients with benign pancreatic duct strictures and impacted pancreatic stones.